Evidence map›Paper›PMID 30909295›Full record

ArticleAnnals of internal medicine2019

Threshold Analysis as an Alternative to GRADE for Assessing Confidence in Guideline Recommendations Based on Network Meta-analyses.

David M Phillippo, Sofia Dias, Nicky J Welton, Deborah M Caldwell, Nichole Taske, A E Ades

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In one paragraph

Article in Annals of internal medicine, 2019. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 40 papers, 19 of them syntheses that pooled it.

0numbers the graph read from it
0cells of the map it votes in
40citing papers in PubMed, 19 pooled it
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

40 citing papers in PubMed, 19 syntheses or guidelines pooled it.

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4 · The record

Corrections and comments

5 · Who and what money

Authors and funding

6 authors.

David M PhillippoUniversity of Bristol, Bristol, United Kingdom (D.M.P., N.J.W., D.M.C., A.A.).
Sofia DiasUniversity of Bristol, Bristol, United Kingdom, and University of York, Heslington, York, United Kingdom (S.D.).
Nicky J WeltonUniversity of Bristol, Bristol, United Kingdom (D.M.P., N.J.W., D.M.C., A.A.).
Deborah M CaldwellUniversity of Bristol, Bristol, United Kingdom (D.M.P., N.J.W., D.M.C., A.A.).
Nichole TaskeNational Institute for Health and Care Excellence, London, United Kingdom (N.T.).
A E AdesUniversity of Bristol, Bristol, United Kingdom (D.M.P., N.J.W., D.M.C., A.A.).

Funding

Medical Research Council MC_U145079307Medical Research Council MR/K025643/1Medical Research Council MR/M005232/1Medical Research Council MR/P015298/1
6 · The paper itself

Abstract

Guideline development requires the synthesis of evidence on several treatments of interest, typically by using network meta-analysis (NMA). Because treatment effects may be estimated imprecisely or be based on evidence lacking internal or external validity, guideline developers must assess the robustness of recommendations made on the basis of the NMA to potential limitations in the evidence. Such limitations arise because the observed estimates differ from the true effects of interest, for example, because of study biases, sampling variation, or issues of relevance. The widely used GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework aims to assess the quality of evidence supporting a recommendation by using a structured series of qualitative judgments. This article argues that GRADE approaches proposed for NMA are insufficient for the purposes of guideline development, because the influence of the evidence on the final recommendation is not taken into account. It outlines threshold analysis as an alternative approach, demonstrating the method with 2 examples of clinical guidelines from the National Institute for Health and Care Excellence (NICE) in the United Kingdom. Threshold analysis quantifies precisely how much the evidence could change (for any reason, such as potential biases, or simply sampling variation) before the recommendation changes, and what the revised recommendation would be. If it is judged that the evidence could not plausibly change by more than this amount, then the recommendation is considered robust; otherwise, it is sensitive to plausible changes in the evidence. In this manner, threshold analysis directly informs decision makers and guideline developers of the robustness of treatment recommendations.

Indexed as

Evidence-Based MedicineHeadacheHumansNetwork Meta-Analysis as TopicPhobia, SocialPractice Guidelines as TopicSensitivity and Specificity

Identifiers

PMID30909295
PMCPMC6739230

What OpenQuestion holds

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Registered trials

None linked

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.